Chapter 32 Common Assessment Abnormalities (objective #5)
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Created by:
Holly_Archer Plus on November 26, 2011
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Yavapai College 2nd Year Second Semester
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Terms | Definitions |
|---|---|
 Distended neck veins | distention greater than 3cm with pt sitting at a 30-45 degree angle.- Possible etiology is elevated right atrial pressure; right sided heart failure. |
| Central Cyanosis | Bluish or purplish tinge to areas such as tongue, conjunctivae, inner surface of lips.- Inadequate O2 saturation of arterial blood due to pulmonary or cardiac disorders. |
| Peripheral Cyanosis | Bluish or purplish tinge in extremities, or in nose and ears.- Reduced blood flow because of heart failure, vasoconstriction, cold environment. |
| Splinter Hemorrhages | small red to black streaks under finger nails.- Infective endocarditis . |
| Clubbing of nail beds | obliteration of normal angle between base of nail and skin.-Endocarditis, congenital defects, prolonged O2 deficiency. |
| Color changes in extremities with postural change | Pallor, cyanosis, mottling of skin after limb elevation; dependent rubor (reddish-blue discoloration), glossy skin.- Chronic decreased arterial perfusion. |
| Ulcers | Venous- necrotic crater-like lesion usually found on lower leg. Characterized by slow wound healing. Arterial- pale ischemic base, well defined edges, usually found on toes, heels, lateral malleoli. |
| Varicose Veins | Visable dilated, discolored, tortuous vessels in lower extremities. - Incompetent valves in vein. |
| Bounding pulse | sharp, brisk, pounding pulse. - hyperkinetic states, anemia, hyperthyroidism. |
| Thready pulse | Weak, slowly rising pulse; easily obliterated by pressure. - Blood loss, decreased CO, aortic valve disease, peripheral arterial disease. |
| Irregular pulse | regularly or irregularly; skipped beats. - Cardiac dysrhythmias. |
| Pulsus alternans | Regular rhythm but strength of pulse varies with each beat.- Heart failure, cardiac tamponade. |
| Absent pulse | lack of pulse. - atherosclerosis, trauma, embolus. |
| Thrill | vibration of vessel or chest wall.- Aneurysm, aortic regurgitation, arteriovenous fistula. |
| Rigidity | Stiffness or inflexibility of vessel wall.- Atherosclerosis. |
| >100 bpm | tachycardia.- Exercise, anxiety, shock, need for increased cardiac output, hyperthyroidism. |
| <60 bpm | bradycardia. - Rest/sleeping, SA or AV node damage, athletic conditioning, side effect of drugs, hypothyroidism. |
| Displaced point of maximal impulse | palpated below the 5th intercostal space and left of the midline. -Left ventricluar dilation. |
| Unusually warm extremities | Hands or feet. - possible thyrotoxicosis. |
| Cold extremities | Hands/feet cold to touch. -Intermittent claudication, peripheral arterial obstruction, low CO, severe anemia. |
| Pitting edema of lower extremities or sacral area | visable indentation after application of firm pressure; weight gain; tightening of clothing. - Interruption of venous return to heart, fluid in tissues. |
| Abnormal capillary refill | blanching of nail bed for >2sec after application of firm pressure is released.- Possible reduced arterial capillary perfusion, anemia. |
| Asymmetry in limb circumference | Measureable swelling in limb. -Venous thromboembolism, varicose veins, lymphedema. |
| Abnormal Cardiac Borders | left border of cardiac dullness extends past MCL in 5th ICS; border of cardiac dullness extends past sternal border. - Cardiac enlargement due to coronary heart disease, heart failure, cardiomyopathy. |
| Pulse deficit | apical HR exceeds the peripheral pulse rate.- Cardiac dysrhythmias; most commonly atrial fibrillation. |
| Arterial Bruit | Turbulant flow sound in peripheral artery.- Arterial obstruction or aneurysm. |
| Third Heart Sound | Extra heart sound, low pitched, heard in early diastole, similar to the sound of a gallop. -Left ventricular failure; volume overload; mitral, tricuspid or aortic regurgitation; HTN. |
| Fourth Heart Sound | Extra heart sound, low pitched, heard in late diastole, similar to the sound of a gallop. -Forceful artrial contraction from resistance to ventricular filling. |
| Cardiac Murmurs | Turbulent sounds occuring between normal heart sounds; characterized by loudness, pitch, shape, quality, duration and timing.- Cardiac valve disorder, abnormal blood flow patterens. |
| Pericardial friction rub | High-pitched, scratchy sound heard during S1 and/or S2 at the apex; heard best with pt sitting or leaning forward, at the end of expiration. -Pericarditis. |
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